Healthcare Provider Details

I. General information

NPI: 1417694530
Provider Name (Legal Business Name): AMANDA JONETTE LARE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2022
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13969 GERMAN CHURCH RD
ATWATER OH
44201-9016
US

IV. Provider business mailing address

206 W VINE ST
ALLIANCE OH
44601-1339
US

V. Phone/Fax

Practice location:
  • Phone: 330-206-7249
  • Fax:
Mailing address:
  • Phone: 330-206-7249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number172225
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: